Healthcare Provider Details

I. General information

NPI: 1477852960
Provider Name (Legal Business Name): NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E MCPHERSON ST
KIRKSVILLE MO
63501-3557
US

IV. Provider business mailing address

1416 CROWN DRIVE
KIRKSVILLE MO
63501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 660-627-5757
  • Fax: 660-627-5802
Mailing address:
  • Phone: 660-627-5757
  • Fax: 660-627-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002241
License Number StateMO

VIII. Authorized Official

Name: ANDREW GRIMM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 660-627-5757